Donald H. Arnold

Parental Knowledge and Use of Preventive Asthma Care Measures in Two Pediatric Emergency Departments

Objectives: Parents of children who visit the pediatric emergency department (PED) for asthma exacerbations may have inadequate knowledge of preventive asthma care. The primary objective of this study was to assess knowledge and use of preventive asthma care measures among parents of children with asthma who present to the PED with asthma exacerbations. The secondary objective was to identify variables that predict adherence to four key preventive care measures. Methods: The authors administered a 38-item questionnaire to 229 parents of children ages 2 to 18 years with asthma exacerbations who presented to two urban PEDs, one in the southeast and one in the northwest United States. Descriptive statistics were calculated to assess parental knowledge of preventive care. Multivariable logistic regression was used to identify variables associated with the use of four key preventive care measures. Results: Thirty-two percent of the children had an action plan, and 52% received the influenza vaccine within the preceding year. Sixty-six percent of the children had persistent asthma by National Institutes of Health (NIH) criteria. Of these, 51% received daily inhaled corticosteroids (ICSs). When parents were asked how an ICS medicine worked, 29% (64/221) responded “immediately opens the airway,” and 24% (53/221) responded “I do not know.” Daily use of ICS in these children was significantly associated with parent education level beyond high school (odds ratio [OR] = 2.81; 95% confidence interval [CI]: 1.26, 6.24; p = .011). Non-African Americans were more likely to have received an action plan than African Americans (OR = 2.18; 95% CI: 1.17, 4.06; p = .014). A secondary analysis of the parents perception of his/her ability to provide care during an asthma exacerbation was significantly associated with receipt of an action plan in a multivariable proportional odds model (OR = 3.63; 95% CI: 1.99, 6.62; p <.001). Conclusions: Parents of children with persistent asthma presenting to urban tertiary care PEDs with asthma exacerbations frequently have inadequate understanding of appropriate ICS use. Parents with less than a high school education, in particular, may benefit from focused educational interventions that address the importance of daily ICS use in asthma control. Parents who receive a written action plan are more confident in their ability to provide care for their child during an asthma exacerbation.

The concept and practice of a wait-and-see approach to acute otitis media

Purpose of review We review the contemporary management of acute otitis media, including symptomatic care, the rationale and literature for utilizing the wait-and-see approach, and the indications for immediate therapy with antibiotics. Recent findings Current guidelines recommend selective use of observation in children diagnosed with acute otitis media. Recent evidence suggests that a wait-and-see approach will reduce the use of antibiotics and decrease adverse events associated with their use. Earlier studies found that antimicrobials reduce pain and discomfort in the acute phase of illness compared with placebo. A recently published trial, however, suggests that when analgesics are utilized there may be minimal or no difference in otalgia whether antibiotics are prescribed or withheld. Summary Treatment of acute otitis media is the most frequent indication for prescribing antibiotics in the pediatric population. Evidence suggests there is marginal benefit from antibiotics for most children diagnosed with AOM. Based on current data, we propose an algorithm for the management of children with AOM that includes a wait-and-see approach with specific indications for immediate treatment with antibiotics. A wait-and-see approach to acute otitis media that empowers families by using a shared decision-making model will reduce the use of antibiotics and will decrease resistance to antimicrobials.

Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure

BACKGROUND Ketamine is widely used for procedural sedation, but there is limited knowledge on whether ketamine use is associated with elevated intraocular pressure (IOP). OBJECTIVE The aim of this study was to examine whether there are clinically important elevations of IOP associated with ketamine use during pediatric procedural sedation. METHODS We prospectively enrolled children without ocular abnormalities undergoing procedural sedation that included ketamine for nonperiorbital injuries. We measured IOP for each eye before and at 1, 3, 5, 15, and 30 minutes after initial intravenous ketamine administration. We performed Bland-Altman plots to determine if IOP measurements in both eyes were in agreement. Linear regression was used to model the mean IOP of both eyes as a function of time, dose, and age, with a robust sandwich estimator to account for repeated measures. RESULTS Among 25 participants, median (interquartile range) age was 11 (9-12) years, and 18 (72%) were male. Median ketamine dose was 1.88 mg/kg (interquartile range, 1.43-2.03 mg/kg; range 0.96-4 mg/kg). Bland-Altman plots demonstrated a mean difference of IOP between eyes near zero at all time points. The largest predicted difference from baseline IOP occurred at 15 minutes, with an estimated change of 1.09 mm Hg (95% confidence interval, -0.37 to 2.55). The association between ketamine dose and mean IOP was not statistically significant or clinically meaningful (P = .90; estimated slope, 0.119 [95% confidence interval, -1.71 to 1.95]). There were no clinically meaningful levels of increased measured average IOP reached at any time point. CONCLUSIONS At dosages of 4 mg/kg or less, there are not clinically meaningful associations of ketamine with elevation of IOP.

Performance of the Acute Asthma Intensity Research Score (AAIRS) for acute asthma research protocols

There are limited validated severity measures for acute asthma exacerbations that can be measured in all subjects regardless of age or ability to cooperate and that are sufficiently comprehensive and sensitive to be used as an outcome measure for research protocols. The 13-point (0 – 12) Pediatric Respiratory Assessment Measure (PRAM) was developed in young children with exacerbations using airway resistance as the reference measure and discriminated baseline severity and responsiveness after treatment.1 We have reported that the RAD score, a simple bedside severity score for pediatric patients with acute asthma exacerbations, performs as well as the PRAM score.2 The PRAM includes scalene retractions (Table), a sign that the PRAM developers noted in only 2% of their participants before treatment. Although the PRAM developers note that a training lecture and demonstration were used for score assessors, to our knowledge this teaching tool has not been reported.1 In addition, it has long been recognized that scalene retractions may be consistently ascertained only by palpation or electromyography and that this assessment may be difficult.3 In a prospective research protocol of pediatric patients with acute asthma exacerbations, we experienced the same difficulty in being able to visually discern scalene muscle retractions. Because of this, we studied the substitution of scalene muscle retractions with visual intercostal and subcostal retractions and expiratory phase prolongation. Table PRAM and AAIRS acute asthma severity score components, values assigned by severity of each component, and ranges of component values comprising each score This modification also allows for an acute asthma severity score with a greater number of relevant components that have been used in previous scores, are easy to observe, and might more fully capture the variability of exacerbation severity needed for research protocols.4 These modifications resulted in a 17-point (0 – 16) Acute Asthma Intensity Research Score (AAIRS) that excludes scalene and includes intercostal and subcostal retractions, as well as expiratory phase prolongation. Our objectives were to assess discrimination of baseline severity and responsiveness of the PRAM and AAIRS and the distributions of score values in children with exacerbations.5–7 To assess score discrimination and responsiveness, we studied a prospective cohort aged 5–17 years presenting to a tertiary, academic pediatric emergency department with acute asthma exacerbations. AAIRS component values were specified a priori (as done by the PRAM developers) and corresponded to those of the PRAM to facilitate comparative assessment of performance.1 Each score was calculated on presentation and after 2 hours of treatment. Predictor variables were baseline PRAM and AAIRS and change of each score after 2 hours of treatment (ΔPRAM, ΔAAIRS). Criterion standard outcome variables used to examine discrimination and responsiveness of each score were percent-predicted forced expiratory volume in 1-second (%FEV1) and 2-hour proportionate change expressed as percent (Δ%FEV1) in those who could perform this test at each time point. We performed linear regression of baseline %FEV1 on baseline PRAM or AAIRS in two separate models. In two other models, Δ%FEV1 was regressed on ΔPRAM or ΔAAIRS, baseline %FEV1, and the baseline value of the corresponding score. Linear spline functions were used in both sets of models to allow for nonlinear relationships between each predictor and the respective outcome. Ninety-five percent confidence intervals (95% CI) were calculated using bootstrap resampling techniques with 1,000 replications. The study protocol was approved by our institutional IRB. Of 661 unique subjects, median [IQR] age was 8.8 [6.9, 11.3], 60% were male, and 59% were African-American. Accessory muscle use was visually observed in: Scalene, 2 (0.3%); sternocleidomastoid, 362 (55%); intercostal, 110 (17%); and subcostal, 113 (17%). Prolonged expiratory phase was noted in 329 (50%) and severely prolonged expiratory phase in 45 (7%). Baseline scores were: PRAM 4 [1, 5], range 0–9 (SD 2.32); AAIRS 5 [1, 8], range 0–14 (SD 3.53). Baseline %FEV1 was 51 [36, 72; n = 430] and Δ%FEV1 27 [9.6, 62; n = 282]. Both scores discriminated baseline severity assessed using %FEV1 (n = 430): PRAM, R2 0.44 (95% CI, 0.37–0.51); AAIRS, R2 0.47 (95% CI, 0.41–0.51). In addition, the adjusted models that included change of each score demonstrated responsiveness in predicting Δ%FEV1 (n = 282): ΔPRAM, R2 0.28 (95% CI, 0.17–0.37); ΔAAIRS, R2 0.28 (95% CI, 0.18–0.34). The AAIRS demonstrates discrimination and responsiveness comparable to the PRAM. Scalene retractions were observed rarely, whereas intercostal and subcostal retractions and expiratory phase prolongation were observed frequently, accounting for the greater range and variability (SD 3.53 vs. 2.32) of AAIRS. The greater range of values of the AAIRS, which substitutes relevant signs we have found to be easier to identify, might provide more comprehensive assessment of acute asthma exacerbation severity for research protocols.2

The RAD score: a simple acute asthma severity score compares favorably to more complex scores

BACKGROUND Acute asthma severity scores facilitate assessment and implementation of timely and appropriate therapy for pediatric patients but are complex and challenging for clinicians to use at the bedside. OBJECTIVE To assess whether a simple, bedside acute asthma severity score comprising 3 standard clinical measures performs as well as more comprehensive asthma scores. METHODS We prospectively enrolled participants 5 to 17 years of age with acute asthma exacerbations. We recorded 3 asthma scores at baseline and after 2 hours of treatment: the Pediatric Asthma Severity Score (PASS), the Pediatric Respiratory Assessment Measure (PRAM), and the RAD score (Respiratory rate; Accessory muscle use; Decreased breath sounds). We assessed each score for criterion validity in predicting baseline percent forced expiratory volume in 1 second (%FEV(1)) and for responsiveness in predicting change of %FEV(1) after 2 hours of treatment using multiple linear regression models adjusted for age, race, sex, and Global Initiative for Asthma chronic control. RESULTS Of 536 participants included for analyses, median age was 8.8 years, 60% were male, and 58% were African American. The 3 acute asthma scores demonstrated similar criterion validity to explain variation of baseline %FEV(1) (R(2): 0.434 [PASS]; 0.462 [PRAM]; 0.426 [RAD]), but none demonstrated clinically significant responsiveness to change in %FEV(1) (R(2): 0.109 [PASS]; 0.106 [PRAM]; 0.139 [RAD]). CONCLUSIONS The RAD score, comprising 3 routinely measured bedside clinical parameters, is a simple and easily used instrument for assessing the severity of an acute asthma exacerbation and has comparable criterion validity and improved responsiveness when compared with 2 more complex acute asthma scores.

Objectives, design and enrollment results from the Infant Susceptibility to Pulmonary Infections and Asthma Following RSV Exposure Study (INSPIRE)

BackgroundRespiratory syncytial virus (RSV) lower respiratory tract infection (LRI) during infancy has been consistently associated with an increased risk of childhood asthma. In addition, evidence supports that this relationship is causal. However, the mechanisms through which RSV contributes to asthma development are not understood. The INSPIRE (Infant Susceptibility to Pulmonary Infections and Asthma Following RSV Exposure) study objectives are to: 1) characterize the host phenotypic response to RSV infection in infancy and the risk of recurrent wheeze and asthma, 2) identify the immune response and lung injury patterns of RSV infection that are associated with the development of early childhood wheezing illness and asthma, and 3) determine the contribution of specific RSV strains to early childhood wheezing and asthma development. This article describes the INSPIRE study, including study aims, design, recruitment results, and enrolled population characteristics.Methods/designThe cohort is a population based longitudinal birth cohort of term healthy infants enrolled during the first months of life over a two year period. Respiratory infection surveillance was conducted from November to March of the first year of life, through surveys administered every two weeks. In-person illness visits were conducted if infants met pre-specified criteria for a respiratory illness visit. Infants will be followed annually to ages 3-4 years for assessment of the primary endpoint: wheezing illness. Nasal, urine, stool and blood samples were collected at various time points throughout the study for measurements of host and viral factors that predict wheezing illness. Nested case-control studies will additionally be used to address other primary and secondary hypotheses.DiscussionIn the INSPIRE study, 1952 infants (48% female) were enrolled during the two enrollment years and follow-up will continue through 2016. The mean age of enrollment was 60 days. During winter viral season, more than 14,000 surveillance surveys were carried out resulting in 2,103 respiratory illness visits on 1189 infants. First year follow-up has been completed on over 95% percent of participants from the first year of enrollment.With ongoing follow-up for wheezing and childhood asthma outcomes, the INSPIRE study will advance our understanding of the complex causal relationship between RSV infection and early childhood wheezing and asthma.

The Acute Asthma Severity Assessment Protocol (AASAP) study: objectives and methods of a study to develop an acute asthma clinical prediction rule

Acute asthma exacerbations are one of the most common reasons for paediatric emergency department visits and hospitalisations, and a relapse frequently necessitates repeat urgent care. While care plans exist, there are no acute asthma prediction rules (APRs) to assess severity and predict outcome. The primary objective of the Acute Asthma Severity Assessment Protocol study is to develop a multivariable APR for acute asthma exacerbations in paediatric patients. A prospective, convenience sample of paediatric patients aged 5–17 years with acute asthma exacerbations who present to an urban, academic, tertiary paediatric emergency department was enrolled. The study protocol and data analysis plan conform to accepted biostatistical and clinical standards for clinical prediction rule development. Modelling of the APR will be performed once the entire sample size of 1500 has accrued. It is anticipated that the APR will improve resource utilisation in the emergency department, aid in standardisation of disease assessment and allow physician and non-physician providers to participate in earlier objective decision making. The objective of this report is to describe the study objectives and detailed methodology of the Acute Asthma Severity Assessment Protocol study.

Estimation of airway obstruction using oximeter plethysmograph waveform data

BackgroundValidated measures to assess the severity of airway obstruction in patients with obstructive airway disease are limited. Changes in the pulse oximeter plethysmograph waveform represent fluctuations in arterial flow. Analysis of these fluctuations might be useful clinically if they represent physiologic perturbations resulting from airway obstruction. We tested the hypothesis that the severity of airway obstruction could be estimated using plethysmograph waveform data.MethodsUsing a closed airway circuit with adjustable inspiratory and expiratory pressure relief valves, airway obstruction was induced in a prospective convenience sample of 31 healthy adult subjects. Maximal change in airway pressure at the mouthpiece was used as a surrogate measure of the degree of obstruction applied. Plethysmograph waveform data and mouthpiece airway pressure were acquired for 60 seconds at increasing levels of inspiratory and expiratory obstruction. At each level of applied obstruction, mean values for maximal change in waveform area under the curve and height as well as maximal change in mouth pressure were calculated for sequential 7.5 second intervals. Correlations of these waveform variables with mouth pressure values were then performed to determine if the magnitude of changes in these variables indicates the severity of airway obstruction.ResultsThere were significant relationships between maximal change in area under the curve (P < .0001) or height (P < 0.0001) and mouth pressure.ConclusionThe findings suggest that mathematic interpretation of plethysmograph waveform data may estimate the severity of airway obstruction and be of clinical utility in objective assessment of patients with obstructive airway diseases.

Diagnosis of Trichomonas vaginalis in Female Children and Adolescents Evaluated for Possible Sexual Abuse: A Comparison of the InPouch TV Culture Method and Wet Mount Microscopy

STUDY OBJECTIVE To compare the performance of wet mount microscopy and the InPouch TV culture method in diagnosing Trichomonas vaginalis in a cohort of female children and adolescents evaluated for possible sexual abuse. DESIGN A prospective study in which samples for both wet mount and InPouch TV were collected from the vaginal vault of each participant. The wet mount was examined microscopically for the presence of motile trichomonads, and the InPouch TV was analyzed in accordance with manufacturer specifications. SETTING A regional, university-affiliated sexual abuse center in Nashville, TN. PARTICIPANTS Females (N = 271) aged 10 to 17 years (inclusive) who met screening criteria for sexually transmitted infection testing in accordance with Centers for Disease Control recommendations, and who exhibited evidence of at least partial hymenal estrogenization. MAIN OUTCOME MEASURES A Trichomonas vaginalis diagnosis either via detection of motile trichomonads on wet mount or a positive InPouch TV. RESULTS The median age of the 271 participants was 13.6 years, 88% (235/268) were genital Tanner stage 4 or 5, and 66% (173/263) were Caucasian. Trichomonas vaginalis was diagnosed by either wet mount or InPouch TV in 4% (12/274) of the possible sexually transmitted infection exposures. The sensitivity of wet mount was 8/12 = 0.67 (95% confidence interval [CI]: 0.39, 0.86) and specificity was 262/262 = 1.00 (95% CI: 0.99, 1.00). The false negative rate of wet mount was 4/12 = 0.33 (95% CI: 0.14, 0.61). CONCLUSIONS A culture-based method such as InPouch TV should be considered for Trichomonas vaginalis diagnosis when evaluating children and adolescents in whom sexual abuse is a concern.

Noninvasive assessment of asthma severity using pulse oximeter plethysmograph estimate of pulsus paradoxus physiology

BackgroundPulsus paradoxus estimated by dynamic change in area under the oximeter plethysmograph waveform (PEP) might provide a measure of acute asthma severity. Our primary objective was to determine how well PEP correlates with forced expiratory volume in 1-second (%FEV1) (criterion validity) and change of %FEV1 (responsiveness) during treatment in pediatric patients with acute asthma exacerbations.MethodsWe prospectively studied subjects 5 to 17 years of age with asthma exacerbations. PEP, %FEV1, airway resistance and accessory muscle use were recorded at baseline and at 2 and 4 hours after initiation of corticosteroid and bronchodilator treatments. Statistical associations were tested with Pearson or Spearman rank correlations, logistic regression using generalized estimating equations, or Wilcoxon rank sum tests.ResultsWe studied 219 subjects (median age 9 years; male 62%; African-American 56%). Correlation of PEP with %FEV1 demonstrated criterion validity (r = - 0.44, 95% confidence interval [CI], - 0.56 to - 0.30) and responsiveness at 2 hours (r = - 0.31, 95% CI, - 0.50 to - 0.09) and 4 hours (r = - 0.38, 95% CI, - 0.62 to - 0.07). PEP also correlated with airway resistance at baseline (r = 0.28 for ages 5 to 10; r = 0.45 for ages 10 to 17), but not with change over time. PEP was associated with accessory muscle use (OR 1.16, 95% CI, 1.11 to 1.21, P < 0.0001).ConclusionsPEP demonstrates criterion validity and responsiveness in correlations with %FEV1. PEP correlates with airway resistance at baseline and is associated with accessory muscle use at baseline and at 2 and 4 hours after initiation of treatment. Incorporation of this technology into contemporary pulse oximeters may provide clinicians improved parameters with which to make clinical assessments of asthma severity and response to treatment, particularly in patients who cannot perform spirometry because of young age or severity of illness. It might also allow for earlier recognition and improved management of other disorders leading to elevated pulsus paradoxus.